
Get Molina Healthcare Provider Dispute Resolution Request 2010-2025
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How to fill out the Molina Healthcare Provider Dispute Resolution Request online
Filling out the Molina Healthcare Provider Dispute Resolution Request is an important step in resolving billing disputes. This guide provides a clear and supportive walkthrough on how to complete the form online, ensuring you provide all necessary information for a successful resolution.
Follow the steps to complete the Molina Healthcare Provider Dispute Resolution Request online.
- Press the ‘Get Form’ button to access the Provider Dispute Resolution Request and open it in your preferred editor.
- Fill in the required fields marked with an asterisk (*), starting with the provider name and tax ID or Medicare ID number, ensuring accurate information.
- Enter the provider address and select the provider type from the available options, including MD, mental health, home health, and more.
- In the claim information section, indicate whether you are submitting a single claim or multiple claims. If multiple claims, complete the attached spreadsheet with the specified number of claims.
- Provide the patient’s name and health plan ID number, along with their date of birth and account number.
- Include the service dates (from/to) as it is required for claims and overpayment disputes.
- Fill out the original claim ID number and original claim amount billed.
- In the dispute type section, check the appropriate box that reflects your reason for the dispute, such as claim resolution, appeal of medical necessity, or contract dispute.
- Clearly describe the dispute and expected outcome in the relevant fields, being specific and providing any additional supporting information if necessary.
- Enter contact information including name, title, phone number, and add your signature and date at the bottom of the form.
- If additional information is needed, check the box indicating attachments and remember not to staple documents.
- Once all information is filled in, save changes, and download or print the form for your records before mailing it to the provided address.
Complete your dispute resolution request online today for a smooth and efficient process.
The four types of dispute resolution include negotiation, mediation, arbitration, and litigation. Each method offers different advantages depending on the nature of the dispute. Negotiation and mediation emphasize collaboration to reach an agreement, while arbitration and litigation involve third-party decisions. Understanding these options can empower you to choose the best path forward in your Molina Healthcare Provider Dispute Resolution Request.
Fill Molina Healthcare Provider Dispute Resolution Request
Requests must be received within 90 days of date of original remittance advice. Please allow 30 days to process requests. Call Molina Healthcare tollfree at (833) 6441623, Monday to Friday, a.m. The Molina Healthcare Provider Resolution Department handles written inquiries from providers regarding claim disputes. The Provider can call Molina Provider Services at Monday through Friday from 8 a.m. This form is a claims reconsideration request form that can be submitted to Molina Healthcare of Ohio within 120 days of the original remittance advice. Call Molina Healthcare tollfree at (833) 6441623, Monday to Friday, a.m. (For use with multiple "LIKE" claims). To submit the Claim Dispute Request Form, you can fax it to or visit our Provider Portal for online submissions. Providers appealing or disputing a claim previously adjudicated must request such action within one (1) year of.
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